Wage Assignment Reduction Request
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1
2State of Wisconsin
DEPARTMENT OF REVENUE
2135 RIMROCK ROAD PO BOX 8901 MADISON WI 53708-8901 Phone (608) 266-7879 FAX (608) 261-8978 delnqtax@revenue.wi.gov
WAGE ASSIGNMENT REDUCTION REQUEST
The Department will inform you if your proposed deduction amount is approved or if additional information is needed. If approved as
proposed, your employer will be sent the updated deduction amount. If it is determined that larger payments are necessary or additional
information is required, someone from the department will contact you. Be sure to complete both pages.
YOUR INFORMATION
SPOUSE INFORMATION
Name
Name
Social Security Number
Social Security Number
Date of Birth
Date of Birth
Address
Address
City, State, Zip
City, State, Zip
Phone (
)
Phone (
)
Name(s) and ages of dependent(s)
Name(s) and ages of dependent(s)
Place of Employment
Place of Employment
Company
Company
Address
Address
City, State, Zip
City, State, Zip
Phone (
)
Phone (
)
Job Title /Position
Job Title/Position
Gross Income
Gross Income
Net Income
Weekly
Bi-weekly
Monthly
Net Income
Weekly
Bi-weekly
Monthly
$
$
Other Income
Other Income
General Assistance
$
General Assistance
$
AFDC
$
AFDC
$
Social Security /SSI
$
Social Security /SSI
$
Other (specify)
$
Other (specify)
$
REQUESTED DEDUCTION AMOUNT
$
Monthly
Additional Information:
1. The Department of Revenue may file delinquent tax warrants. These warrants are liens against your property and, as public records,
may affect your credit rating. The filing of these tax warrants will add additional charges to your balance.
2. Your Wisconsin tax refunds will be used to reduce the unpaid tax liability and will not be considered wage assignment payments on
your agreement.
3. All returns and taxes must be filed and paid as they become due.
4. The Wisconsin Department of Revenue reserves the right to void any agreement if it is determined that it was made based on false or
inaccurate information or if there is a material change in your financial condition.
I/ We attest that the information furnished on this form is true and correct to the best of my/our knowledge.
Taxpayer
Date
Spouse
Date
A-772 (R. 10-08)
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